EyetubeFLACS with Toric and iStent Inject

This surgical demonstration video showcases femtosecond laser-assisted cataract surgery combined with toric IOL implantation and iStent inject placement, representing an advanced approach to simultaneous treatment of cataracts, corneal astigmatism, and glaucoma. The video provides technical guidance on integrating multiple surgical interventions in a single procedure, valuable for surgeons considering adoption of combined techniques. Posted in 2019, the techniques represent established but advanced cataract surgery methodology.

🔍 Key Clinical Considerations

• Surgical Integration Complexity: Combining FLACS with toric lens alignment and trabecular micro-bypass stent placement requires precise surgical planning, femtosecond laser programming for capsulotomy and lens fragmentation, and intraoperative coordination of multiple device placements.
• Patient Selection Criteria: Ideal candidates present with visually significant cataracts, corneal astigmatism warranting toric correction (typically ≥0.75D), and mild-to-moderate open-angle glaucoma suitable for trabecular bypass procedures rather than traditional filtration surgery.
• Astigmatism Correction Precision: Toric IOL placement demands accurate preoperative keratometry, precise axis marking, and intraoperative alignment verification, with femtosecond laser-created capsulotomy potentially improving centration and rotational stability compared to manual techniques.
• Glaucoma Management Integration: iStent inject placement targets Schlemm’s canal at the trabecular meshwork, providing IOP reduction through enhanced aqueous outflow, with studies showing 20-30% pressure reduction and medication burden decrease in appropriate candidates.
• Technology Learning Curve: Femtosecond laser integration requires additional training, surgical time initially increases by 10-15 minutes, and surgeons must develop proficiency with laser interface programming and managing laser-related complications like anterior capsule tags or incomplete lens fragmentation.

💡 Clinical Practice Impact

• Patient Communication: Surgeons should explain that combined procedures address multiple conditions simultaneously—cataracts, astigmatism reducing glasses dependence, and glaucoma pressure management—while discussing extended surgical time, additional device costs potentially affecting out-of-pocket expenses, and realistic expectations for glasses independence and pressure control outcomes.
• Practice Integration: Adopting this surgical approach requires femtosecond laser availability and maintenance contracts, iStent device inventory management, staff training on laser operation and device handling, and updated consent processes addressing each intervention’s risks including laser-related complications and stent migration or blockage.
• Risk Management: Document detailed preoperative planning including axis marking photography, obtain informed consent for each component (laser, premium toric IOL, glaucoma device), and establish protocols for managing combined-procedure complications such as incomplete laser fragmentation requiring manual completion or suboptimal toric alignment necessitating repositioning.
• Action Items: Consider case selection starting with straightforward cataracts and moderate astigmatism before advancing to complex cases, establish relationships with industry representatives for training support, and track outcomes including uncorrected visual acuity, residual astigmatism, and IOP reduction to assess surgical proficiency development.
• Surgical Technique Refinement: Review procedural steps including femtosecond laser capsulotomy and fragmentation parameters, toric lens insertion and alignment verification techniques using built-in or external marking systems, and iStent inject placement visualization strategies using gonioscopy or direct visualization approaches for optimal trabecular meshwork access.

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